Case 4

19-year-old female with sports injury - Christina

Martinez
Author: Stella King, M.D., M.H.A., University of Buffalo
Learning Objectives:
Create a differential diagnosis for ankle pain. 1.
Know how to perform a focused history and physical appropriate for painful
joints.
2.
Know the signs and symptoms of life/limb-threatening injuries. 3.
Describe the use of nonsteroidal anti-inflammatory drugs (NSAIDs) for
strains/sprains.
4.
Be able to utilize evidence-based medicine indications for radiologic
evaluation of ankle injury.
5.
Construct a treatment plan for ankle pain, including RICE (Rest, Ice,
Compression, Elevation).
6.
Be able to provide counseling to the patient regarding injury prevention. 7.
Understand the role of the family medicine physician in treating ankle
injuries
8.
Summary of Clinical Scenario: Christina Martinez is a 19-year-old Hispanic
female with no significant past medical history who presents today with complaint
of right ankle pain since an inversion injury yesterday at a soccer game. She was
able to walk off the field, but today she complains of pain along the lateral aspect
of the ankle as well as slight swelling and declines to walk without assistance. Her
mother insists on an x-ray to rule out a fracture; but history, physical, and Ottawa
ankle rules do not indicate a need for x-rays. The student learns how to deal with
a patient demanding expensive tests that are not indicated. After Christina is
counseled regarding treatment of her sprained ankle, she mentions she has also
been experiencing dysuria. Based on her history, a presumptive diagnosis of
urinary tract infection is made. Appropriate treatment is discussed, and plans are
made for a follow-up appointment.
Key Findings from History
Teenager
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Pain
No previous history of ankle
injury
Acute
No sensory changes
No stiffness
Key Findings from Physical
Exam
No deformity
Warm ankle
No swelling
Differential Diagnosis
Sprain
Fracture of distal fibula
Fracture of talus
Peroneal tendon tear
Subtalar injury
Key findings from Testing Not applicable
Final Diagnosis Ankle sprain
Case Highlights: How to approach a patient with family members in the room.
Keeping immunizations up to date: Finding and applying the Centers for Disease
Control (CDC) immunization schedule. The importance of understanding patient
perspective for effective care. Taking care to address the patients concerns. How
to answer a patients questions about diagnosis when all necessary information
has not yet been gathered.
Key Teaching Points
Knowledge:
Acute ankle injury statistics:
One of the most common musculoskeletal injuries
Accounts for 2 million injuries per year and 20% of all sports injuries in the
United States
Despite the fact that ankle injuries are the most common presentation to
the emergency department, less than 15% of these injuries turn out to be
clinically significant fractures.
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Compartment syndrome:
Serious life and limb-threatening complication of extremity trauma.
Rising pressure in a muscle compartment impairs perfusion to that same
muscle compartment.
Causes: Fractures, crush injuries, burns, and arterial injuries.
Need high clinical suspicion, as delay in diagnosis or treatment can lead to
compromised blood supply, nerve damage, and muscle death.
Treatment: Emergent decompression via fasciotomy
Signs and symptoms (the 6 Ps):
Pain (hallmark sign)
Pallor
Pulselessness
Paresthesias (burning, itching, prickling, or tingling): The most reliable
sign
Poikilothermia (inability to regulate body temperature)
Paralysis
Dysuria:
Symptoms of upper urinary tract infection (pyelonephritis) are fever, chills,
severe abdominal or back pain. On exam, costovertebral angle (CVA)
tenderness pain may be elicited by tapping on the upper back, just below
the ribs.
Abnormalities on urinalysis associated with urinary tract infection include
positive leukocyte esterase and nitrites.
Skills
History
Address patients concerns: Early in the visit, elicit and prioritize the patient
concerns. (This does not mean that all of them will be addressed at this visit. It
may be necessary to bring the patient back for return visits until his or her needs
have been adequately met.)
Interviewing a patient when additional people are in the room:
Greet each individual and identify his/her role in the visit.
The patient's confidentiality must be maintained at all times. If any doubt
exists regarding a specific issueparticularly if any conflict develops during
the discussionthe patient's permission must be obtained before proceeding
with the discussion.
Taking a history of ankle injury:
Ask if the issue is acute or chronic.
Gather underlying medical history.
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Know the patient's age.
If acute injury, gather a complete history regarding the timing and
mechanism of injury (MOI):
Most common MOI for ankle sprain: Plantarflexion and inversion.
Medial ankle sprain MOI: Forced eversion and dorsiflexion. Because of
the bony articulation between the medial malleolus and the talus,
medial ankle sprains are less common than lateral sprains.
Ask about history of previous ankle sprain, as it is a common risk factor for
ankle injury.
History of a snap or tear is diagnostically significant in an acute knee injury,
but not in an acute ankle injury.
A patient who seeks help immediately and is non-weightbearing is more
likely to have a severe injury than one who presents a few days after an
incident and is fully weightbearing.
Taking a history of dysuria:
When did you first notice the problem with burning on urination?
Are you urinating more times than usual during the day or night?
Do you have any pain in the lower part of your belly?
Do you have any lower back pain?
Any fever or chills?
Have you used any medication for this problem?
Ever had symptoms like this before?
Any discharge or itching in your pelvic area?
Are you sexually active?
Immunization history:
The immunization history often is overlooked when patients do not come in
expressly for a prevention visit. But the immunization history is significant, even
in an acute visit such as this one, as another opportunity to update immunizations
may not present itself for a while.
Physical Exam
Lower extremity exam:
Examine the uninjured leg before the injured leg.
Excessive swelling and pain can limit an examination up to 48 hours after
injury.
Visually inspect for bruising, erythema, and swelling.
Check for warmth over the injured area with the back of your hand.
Palpate the dorsalis pedis pulse and check sensation on the plantar and
dorsal aspects of both feet.
Look for edema and pain with palpation over the lateral and medial malleoli,
dorsum of the foot, midfoot, and Achilles tendon.
Test patients ability to move toes, plantarflex, and dorsiflex.
Assess gait.
Assess lateral stabilizing ligaments (anterior talofibular, calcaneofibular, and
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posterior talofibular ligaments), which are the most often in damaged ankle
injuries caused by plantarflexion and inversion injuries:
Anterior drawer test: Assesses integrity of the anterior talofibular
ligament (most easily injured). The knee is flexed 90 degrees. One
hand holds the lower tibia and exerts a slight posterior force while the
other hand, holding the posterior aspect of the calcaneus, attempts to
bring the calcaneus and talus forward on the tibia. If the ligament is
torn, the talus will subluxate anteriorly.
Inversion test (or talar tilt): When ankle is inverted, it does not
appear lax, indicating that the calcaneofibular ligament is intact.
The posterior talofibular ligament: Strongest of the lateral complex,
rarely injured.
Assess for high ankle sprain secondary to eversion and rotation injury or
hyper-dorsiflexion (much less common MOI than plantarflexion and
inversion).
Crossed-leg test: Detects high ankle tibiofibular syndesmotic sprain.
While patient is sitting with one leg crossed over the other, pressure is
applied to the medial side of the knee. A high ankle sprain will
produce pain in the syndesmosis area.

Lateral ankle and stabilizing ligaments:

Grading Ankle Sprains
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Grade I Grade II Grade III
Stretching and/or
small tear of a
ligament.
Incomplete tear
Complete tear and loss of
integrity of the ligament.
Slight to no
functional loss.
Moderate functional
impairment, some
loss of motor
function. Difficulty
bearing weight.
Inability to bear weight
(unable to take four steps
independently).
Mild tenderness
Tenderness over
involved structures
and mild to
moderate pain

Mild swelling.
Mild to moderate
swelling
Severe swelling (greater
than 4 cm about the
fibula)
Usually no
ecchymosis.
Ecchymosis common Ecchymosis present
No mechanical
instability: no
stretching or
opening of the joint
with stress
Moderate instability:
stretching of the
joint with stress, but
a definite stopping
point
Mechanical instability:
significant stretching of
the joint with stress
without a significant
stopping point
Differential diagnosis:
Sprain: The most common acute ankle injury is a lateral ankle inversion
sprain caused by a combination of plantarflexion and inversion. Because of
the bony articulation between the medial malleolus and the talus, medial
ankle sprains are less common than lateral sprains. In medial ankle sprains,
the mechanism of injury is excessive eversion and dorsiflexion. Medial ankle
stability is provided by the strong deltoid ligament, the anterior tibiofibular
ligament, and the bony mortise.
In general, ankle sprains present acutely (after trauma) with pain, warmth,
and swelling. Usually no gross deformity, although if there is a large amount
of swelling, there may appear to be a deformity. Symptoms generally
improve over time. After an ankle sprain, the joint may develop stiffness if
not exercised within the first few days.
1.
Peroneal tendon tear: Usually due to an inversion injury or repetitive
trauma. May occur in conjunction with ankle sprain. Patient may complain of
persistent pain posterior to the lateral malleolus. Swelling may or may not
be present.
2.
Talar dome fracture: May occur in conjunction with an ankle sprain, and
initial x-rays may miss a talar dome fracture. Repeat imaging may be
3.
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required if symptoms persist to detect avascular necrosis. Overall prognosis
is related to potential for interruption of the blood supply.
Fibular fracture: Usually due to falls, athletic injury, or high velocity
mechanism, such as a motor vehicle accident. Patient may present with
severe pain, swelling, bruising, deformity, and inability to walk.
4.
Tendonitis: Ankle tendonitis is an inflammatory condition, usually involving
the posterior tibialis tendon. Swelling/warmth may be present in the
affected area in addition to stiffness. Tendonitis tends to worsen initially
with aggravating activity only; it may then progress to discomfort at any
time. The pain of tendonitis is chronic, usually worse during the day and
after exercise.
5.
Subtalar injury: Often due to a high-energy injury. A dislocation involves
the talocalcaneal and talonavicular joints. Pain, swelling, and deformity are
present.
6.
Less likely diagnoses:
Tarsal tunnel syndrome: Entrapment of the tibial nerve. Symptoms
include pain, tingling, and burning sensations along the sole of the foot. Pain
along the inside of ankle and/or bottom of feet and shooting pain suggests
this diagnosis.
1.
Syndesmotic injury: Generally involves the interosseus membrane and
the anterior inferior tibiofibular ligament. Pain and disability are often out of
proportion to the injury. One would expect a positive ankle squeeze test.
2.
Infection of the joint: Less common. Appropriate history and physical
examination should be obtained. Symptoms include painful range of active
and passive motion, edema, erythema, warmth, and fever.
3.
Arthritis of the ankle: Less common than in some other joints. Chronic
process, more commonly seen in older people. The tibiotalar joint is
generally involved, and condition may occur as a result of prior injury,
obesity, or history of rheumatoid disease. Symptoms may include stiffness,
swelling, deformity, and a feeling of instability.
4.
Tibial fracture of tibia: Typically follows a high velocity trauma. Often the
patient experiences severe pain and is unable to bear weight at all. There
may be visible malformation of the extremity.
5.
Pathologic fracture: A bone broken by factors other than trauma. Usually
associated with metastatic disease.
6.
Achilles tendon rupture: Often characterized by immediate pain and
swelling, inability to plantarflex normally, and significant difficulty with
ambulation. Patient may also experience a popping or snapping sound at
time of injury.
7.
Studies
Patient demands for tests should not be followed if they are in conflict with what is
medically appropriate for the patient. However, you must attempt to understand
what concerns may underlie the demands and try to fully address these issues for
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optimal patient satisfaction.
The Ottawa Rules
Clinical decision tool designed to help in evaluation of adults (! 18 years)
with acute ankle and midfoot injuries
Sensitivity 97100%
Recently, also used to exclude fractures in children > 5 years presenting
with ankle and midfoot injuries
Radiographs of the ankle are needed if:
There is pain in the malleolar zone AND either:
Bony tenderness along the distal 6 cm of the posterior edge of
either malleolus OR
Inability to bear weight both immediately and in the emergency
department.
Radiographs of the foot are needed if:
There is pain in the midfoot region AND one of the following:
Bony tenderness at either the navicular bone or base of the fifth
metatarsal OR
Inability to bear weight both immediately and in the emergency
department.
Management:
Ankle sprain
RICE 1.
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Rest for the first 72 hours only, as not moving the ankle for a longer period
of time can cause more harm, such as decreased range of motion,
persistent pain and swelling, and chronic joint instability.
Ice several times throughout the day for ten minutes at a time reduces
swelling and may help with pain control.
Compression with tape, elastic wrap, or semi-rigid ankle support. (The latter
leads to quicker return to sports and work and less instability of the ankle.)
Elevation also helps to reduce swelling.
Anti-inflammatory medication 2.
Associated with improvement in pain, function, and swelling. Instruct
patients (without contraindications) to take two or three ibuprofen (400 to
600 mg) at a time for pain, up to three times daily, as needed. Ibuprofen
should be taken with food.
Daily ankle exercises 3.
Ankle inversion, ankle eversion, ankle plantarflexion, ankle dorsiflexion,
calf-stretching, and single-leg balancing. Proprioceptive exercises help
prevent and reduce the likelihood of re-injury.
Avoid potential re-injury 4.
Avoid flip-flops or sandals and activities such as soccer until re-evaluation
(usually one week).
Dysuria:
If patient has no history of allergy to sulfa, trimethoprim-sulfamethoxazole
may be used for empirical treatment for uncomplicated lower urinary tract
infection.
A quinolone such as ciprofloxacin may be used in communities with known
high uropathogen resistance to trimethoprim-sulfamethoxazole
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